DMSD/28/2 Information Cut-off Date: 2 Jan 05
6 Jan 05
MEDICAL INTELLIGENCE ASSESSMENT
REPUBLIC OF INDONESIA
NORTH SUMATRA (ACEH PROVINCE)
Serial Content 1 Political Map – Western Indonesia 2 Introduction
3 Description of Province
4 Profile of Diseases of Operational Importance 5 Hazards Associated with Corpses 6 Profile of Environmental Risks of Operational Importance
7 Medical Capabilities Assessment 8 Conclusions
Annex A Description of Medical Treatment Facilities
POLITICAL MAP – WESTERN INDONESIA
1. Aim. The aim of this assessment is to provide information on environmental
conditions, diseases and vectors which may be present in the area under review,
together with an overview of its current medical capability, in order to facilitate
management of manpower wastage due to Disease and Non Battle Injury (DNBI), and
to help inform the needs assessment process for disaster relief operations. This takes
into account specific threats to health posed by the earthquake and subsequent
tsunami that hit northern Sumatra on 26 Dec 04.
2. Sources. The assessment is largely based on information provided by Medical
Intelligence assets from the US and Australia supplemented by intelligence derived
from a number of other sources, both military and civilian.
3. Note to Users. Comments on the accuracy and validity of this assessment are welcomed, and should be passed through the chain of command via Medical channels
to SO2 EIH/CBRN DMSD, Main Building. Whitehall, London SW1A 2HB (Tel:
0207 807 0449).
DESCRIPTION OF PROVINCE
4. Topography. Aceh is a large province with an area of 55,392 sq. km and a population estimated at 4.2 million (2000). It borders the Malacca Strait on the east
and the north and the Indian Ocean on the west. The Bukit Barisan mountain range
rises from the northern part of Aceh along the entire length of Sumatra. It consists of
four municipalities: Banda Aceh, Sabang, Lhokseumawe and Langsa. Banda Aceh,
the largest city, is located at the northern tip of the west coast.
5. Climate. It has a tropical climate and is currently experiencing the wet season which extends from September to February. Rainfall is more significant in the
south, averaging 1000 to 2000 mm per year. Temperatures in the coastal areas range
between 23 and 32 degrees Celsius with relative humidity between 65 and 95 per cent.
Some winds result in very large waves on the west coast in the latter half of the year.
High temperatures and humidity currently around 92 per cent will pose health threats
and unacclimatised personnel will be sensitive to heat and sun-exposure conditions.
High levels of UV radiation present additional hazards. Hypothermia may be
experienced if people are trapped in floodwaters for extended periods.
PROFILE OF DISEASES OF OPERATIONAL IMPORTANCE
6. Meningococcal Meningitis.
a. Incubation Period. Two to 10 days; usually 3 to 4 days.
b. Transmission. Direct contact, including droplets and discharges from
noses and throats of infected persons
c. Risk Period/Distribution. Probably year-round and countrywide.
Risk will be increased in the current overcrowded living conditions and for
personnel having close prolonged contact with the local population.
d. Remarks. Endemic. No reliable epidemiological data exists.
7. Acute Respiratory Diseases. Acute respiratory transmitted infections due to a variety of viral and bacterial agents, including influenzaand measles, are likely to be
of significant concern. Potential overcrowding combined with lack of hand-washing
and basic personal hygiene will promote transmission. Measles, highly communicable
by the respiratory route, is a particular concern for non-immunised children, and could
cause significant mortality. Measles immunisation for this group is a high priority.
8. “Traveller‟s Diarrhoea”and General Diarrhoeal Diseases.
a. Incubation Period. Usually 6 hours to 10 days.
b. Transmission. Primarily by the ingestion of contaminated food and
c. Risk Period/Distribution. Year-round. Countrywide.
d. Remarks. Highly endemic, with risk greatly increased by current
conditions. Attack rates are likely to be extremely high in new arrivals unless
strict precautions are taken. The following causative agents have been
identified: enterotoxigenic E coli(ETEC), Shigella spp, Salmonella spp,
Campylobacter spp, Entamoeba histolytica, Giardia lamblia, Cryptosporidium
spp and a number of viral agents.
9. Typhoid and Paratyphoid Fevers.
a. Incubation Period. One to 3 weeks.
b. Transmission. Ingestion of causative organism in food and water
contaminated by faeces or urine of infective persons.
c. Risk Period/Distribution. Year-round. Countrywide, with elevated
risk in populated areas with poor sanitation.
d. Remarks. Highly endemic. During the early 1990s, an estimated 600
000-1.3 million cases occurred annually. It is reportedly one of the 5 leading
causes of death of the indigenous population. Multiple drug resistant strains
of Salmonella typhi have been reported. Risk is likely to be increased under
a. Incubation Period. Six hours to 5 days; usually 2 to 3 days.
b. Transmission. Ingestion of causative agent, primarily in water
contaminated with faeces or vomit from infective humans.
c. Risk Period/Distribution. Year-round, with risk increasing during the
peak rainy season (usually Dec-Feb) and the peak dry season (usually Jun-
Sep). Countrywide in areas where sanitation and hygiene are low.
d. Remarks. Endemic, with frequent outbreaks. Risk is likely to become
acute under current conditions, unless and until protected water supplies and
sanitation can be established.
11. Viral Hepatitis A and E.
a. Incubation Period. Fifteen to 65 days.
b. Transmission. Hepatitis A is primarily transmitted person-to-person
by the faecal-oral route; Hepatitis E is primarily spread via contaminated
c. Risk Period/Distribution. Year-round and countrywide.
d. Remarks. Hepatitis A is endemic at high levels. Hepatitis E virus
infection is endemic. Risk is likely to become acute under current conditions,
unless and until protected water supplies and sanitation can be established.
12. Helminths. A wide range of intestinal helminths are known to routinely occur,
including Echinococcus. Hookworm larvae that enter the body through unprotected feet are likely to be present in faecally-contaminated mud and water.
VECTOR BORNE DISEASES
a. Incubation Period. Twelve to 14 days.
b. Transmission/Vector Ecology. Bite of an infective mosquito
(Anopheles spp). Numerous vector species occur utilising a wide range of
breeding habits, from brackish waters along coastal areas to clear streams in
hilly areas. The majority of species will feed indoors as well as out.
In November, an outbreak of Plasmodium c. Risk Period/Distribution. Year-round, risk may be elevated during vivax malaria was reported in West Sumatra. Chloroquine resistant the rainy season (usually Nov-May). Countrywide up to 1 500m elevation, Plasmodium vivax has been reported from Nias island off the north-western except for major metropolitan areas.coast of Sumatra. Plasmodium falciparum is reported at low levels.
d. Remarks. Focally endemic at moderate to high levels. The immediate
risk of acquiring malaria in the areas inundated by seawater is likely to be
reduced in the short-term, as breeding sites will have been scoured. Mosquito
populations can, however, be expected to re-establish within weeks, especially
given the current monsoon rains.
14. Arboviral Fevers . A number of arthropod borne fevers are likely to be
encountered, especially in jungle areas. Risk is likely to be increased during and at
the end of the rainy season (usually Nov-May). The immediate risk of acquiring these
diseases in the areas inundated by seawater is likely to be reduced in the short-term, as
breeding sites will have been scoured. Arthropod populations can, however, be
expected to re-establish within weeks, especially given the current monsoon rains.
15. Scrub Typhus.
a. Incubation Period. Six to 21days (usually 10-12 days).
b. Transmission. Bite of an infective larval stage of trombiculid mites,
probably Leptotrombidium deliensis or L. flecheri.
c. Risk Period/Distribution. Jungle areas, especially previously cleared
areas which have experienced limited regrowth (secondary jungle). Risk may
be elevated during dry periods when vector activity is highest. Countrywide
in discrete rural foci.
d. Remarks. Focally enzootic in areas of forest, oil palm, brush and
scrub. Although few indigenous cases are currently .reported, “high rates” of
seroactivity to the causative agent (Rickettsia tsutsugamushi) have been
reported from agricultural communities. This is unlikely to be an immediate
16. Dengue Fever.
a. Incubation Period. Three to 14 days (usually 5-7 days).
b. Transmission/Vector Ecology. Bite of Aedes spp mosquito, usually Ae.
aegypti (a peri-domestic species which breeds in man-made water-holding
containers)or Ae. albopictus (a species which utilises both man-made and
natural water-holding containers in both urban and rural settings). Both
species have a limited flight range.
c. Risk Period/Distribution. Year round, with elevated risk during and at
the end of the rainy season, and countrywide. Vector is active during day.
Risk is elevated in urban and peri-urban areas.
d. Remarks. Endemic at moderate to high levels. Outbreaks of dengue
fever/dengue haemorrhagic fever/dengue shock syndrome (DF/DHF/DSS) all
occurred countrywide during the mid-1990‟s, and by summer 1996, there had
been over 5 300 cases of DF (117 deaths) in the 12 previous months alone.
17. Japanese Encephalitis (JE).
a. Incubation Period. Five - 15 days.
b. Transmission/Vector Ecology. Bite of an infective mosquito (Culex
spp, usually Cx. tritaeniorhynchus), frequently associated with rice-growing
c. Risk Period/Distribution. Year-round, with elevated risk during the
rainy season. Risk is elevated in pig-farming areas. Human cases have been
reported from Sumatra.
d. Remarks. Focally enzootic at moderate to high levels. This is
considered not to be an immediate risk.
18. Viral Hepatitis B, C and D.
a. Incubation Period. Fifteen to 180 days.
b. Transmission. Percutaneous and permucosal exposure to infective
c. Risk Period/Distribution. Year-round and countrywide.
d. Remarks. Hepatitis B virus (HBV) is endemic at moderate to high
levels. Hepatitis C is endemic. Hepatitis D probably occurs, based on
regional data. These diseases are likely to pose a significant risk to those
treating casualties and handling corpses.
19. Sexually Transmitted Diseases. The endemicity of a number of STD, including syphilis, is low to moderate. AIDS/HIV is endemic at increasing levels, and
reported Government numbers are stated by some sources to be probably an
underestimate – Islamic sensitivities regarding the disease are a factor, as is poor
reporting. Condom use is not approved of by the Government. As in other Asian
countries, the disease is largely heterosexual in transmission.
a. Incubation Period. Four - 19 days; usually 10 days.
b. Transmission. Skin contact with water or moist soil
contaminated with urine from infected animals.
c. Risk Period/Distribution. Year-round and countrywide. Elevated risk
may be associated with areas of stagnant water and muddy soils.
d. Remarks. Enzootic at low levels. Few human cases are officially
reported. Risk is usually occupationally associated (oil palm workers, rubber
estate workers and labourers in rural and forested areas). Rats constitute the
main enzootic reservoir. Given the potential for an increase in the rodent
population, the risk of acquiring this disease is significant, and likely to
21. Rabies. Rabies is endemic at high levels and the possibility of aggressive,
hungry dogs biting humans is increased under the present circumstances
HAZARDS ASSOCIATED WITH CORPSES
22. General. It is assessed that the unburied remains of humans killed from
trauma associated with the south Asia tsunamis do not directly pose a significant
infectious disease threat to the local populations or to deployed personnel operating in
the region. Infectious disease agents do not generally survive long in the body after
death. Surviving trauma victims therefore present a much more important reservoir of
23. Contamination of Water Supplies. Cadavers in contact with local potable
water systems have been rarely associated with transmission of bacterial or viral
gastrointestinal diseases. Currently, water supplies in all affected regions are much
more likely to be contaminated due to extensive damage to sanitation systems.
24. Fly-borne Diseases. Adult filth flies feeding on contaminated material such as faeces, refuse and rotting corpses can mechanically transfer contaminated material
directly to humans and human food supplies. An increased density of filth flies,
serving as mechanical vectors, could increase the risk of acquiring bacterial diarrhoeal
such as shigellosis.
25. Mosquito-borne Diseases. Common mosquito-borne diseases in humans such as malaria and dengue fever are not efficiently spread from dead bodies. Additionally,
mosquito vectors are attracted to the carbon dioxide produced by living humans;
therefore, corpses would not attract these vectors.
26. Direct Contact. Specialist personnel such as pathologists, mortuary staff, and body retrieval teams handling human remains have a potential risk of exposure to
hepatitis B virus (HBV) and human immunodeficiency virus (HIV). For all others,
blood and body fluid exposures are minimal, and the risk of contracting HBV is very
low; the risk of contracting hepatitis C virus or HIV approaches zero. Transmission is
relatively inefficient for these diseases, requiring percutaneous exposure (from a
needle stick or exposure from sharp penetrating object); direct contact with mucous
membranes such as eyes, nose, or mouth; or direct contact with non-intact skin
(abraded, chapped, or afflicted with dermatitis). Exposures on intact skin are not a risk
for these blood-borne infections.
PROFILE OF ENVIRONMENTAL RISKS OF OPERATIONAL IMPORTANCE
27. General Environmental Health Risk Assessment. Rapid urbanisation has
outpaced the government‟s ability to provide public sanitation and potable water.
Water, air and soil pollution occurs throughout the country, but is most severe in
urban areas. High heat and humidity in the lowlands present exposure risks.
28. Water Supply.
a. Sources. Indonesia has sufficient water resources, including rivers,
streams and ground water sources. Many residents use bottled water.
b. Treatment/Distribution. Overall, municipal water is supplied to
approximately 40% of urban and rural populations. Throughout the country,
water distribution systems are antiquated, poorly maintained and unable to
keep pace with demand, contributing to contaminated tap water. Urban
distribution systems provide either in-house hook-ups or, more commonly,
public standpipes. Most slum dwellers obtain water from heavily silted rivers,
drainage canals or raw rainwater catchments. Salt water intrusion is rapidly
deteriorating many ground water sources. Water supply infrastructure has
been destroyed and/or polluted throughout the affected part of the province.
No local supply should be considered to be potable unless adequately
tested for microbiological and chemical contamination.
29. Chemical Hazards. Chemical hazards may include soil and surface water
contaminated with petroleum products from power plants, boats, ships, vehicles, and
fuel storage tanks; chlorine products associated with the treatment of swimming pools
in resort areas and waste water treatment plants; transformers containing
polychlorinated biphenyls (PCB), and pesticides containing organophosphates.
Additionally, food sources in the disaster area may have been exposed to chemical
and faecal contamination. The possible health effects from exposure to chemical
contaminants potentially released during the earthquake and tsunami event are listed
in the table below:
POTENTIAL ENVIRONMENTAL HEALTH CONTAMINANTS
POST-TSUNAMI SOUTH-EAST ASIA
Ser Contaminant Potential Health Effects
(a) (b) (c)
1 Petroleum products Petroleum products contain polycyclic aromatic
hydrocarbons (PAH). Exposure to low levels of
PAHs presents a low short-term health risk
including respiratory and central nervous system